Difficulty: Medium
Average Score: 62%
Simulated
The nurse working in the maternity ward is caring for a 24-hour post-partum client. When assessing the client, the nurse notes that her fundus is firm at the level of the umbilicus and is veering a little bit to the right. The initial action for the nurse is to:
Correct answer
A
Rationale
A fundus veering to the right suggests bladder distention (A), which can displace the uterus. Blood pressure (B), oxytocin (C), and pad count (D) are secondary unless other symptoms are present.